A Peek into the ACO Crystal Ball

What care coordination tools will be instrumental to lay the groundwork for ACOs

Now that the final rule has been released for the Centers for Medicare & Medicaid (CMS) Shared Savings Program, what’s in store for the industry? HCI Associate Editor Jennifer Prestigiacomo spoke with American Medical Group Association’s John Cuddeback, M.D., Ph.D., chief medical informatics officer of Anceta, AMGA’s collaborative data warehouse [AMGA is based in Alexandria, Va.], to see what was in store for development of accountable care organizations (ACOs) this year and what care coordination tools will be necessary to lay the groundwork.

What do you think about the ACO final rule? Will it be enough of a catalyst to encourage organizations to go down this path?

In thinking about how the industry will change models over time, this is only one component. There are a lot of our members that are actually talking with their commercial payers about things like an ACO. It may not be exactly the same model, but there is some element of shared savings.

When we talk to medical groups, we hear lots of different models being considered, but they’re all in the same direction. I think the direction of focusing on and managing population health effectively, and sharing savings that result, is very much behind the movement we see in the market.

John Cuddeback, M.D., Ph.D.

Do you think CMS is doing enough to encourage ACOs?

This is a big battleship we’re turning around here. If you look at what the U.S. spends on healthcare, it’s the world’s fifth largest economy. So, it doesn’t change on a dime. It has a lot of infrastructure needs. I think if we look at conceptually at where the direction of where the market is going, I think the recognition that we need to focus on managing population health and paying for population health, as opposed to paying for individual services, is a very clear direction. I think most of our members are very comfortable with that, and that is precisely what AMGA has been advocating for almost a decade.

Much of the toolset available in the industry is focused around the care of an individual patient putting clinical decision support effectively into an EHR, which we’ve all found is a lot harder than it looks, because of the problem of alert fatigue and all of those subtle issues. That is the toolset that much of the industry is still trying to implement. More than 90 percent of our members are already using EHRs, and the majority of those are doing e-prescribing. I think a good model for an ACO was the Physician Group Practice Demo Program. It was a tremendous learning experience that CMS facilitated for the industry as a whole. Of their 10 participants, nine were medical groups, and all were AMGA members.

People talk a lot about care coordination and patient-centered medical home, which is a model that we absolutely support. If you look at the typical Medicare patient, who sees seven physicians a year, two different primary care physicians and five specialists, [you realize]that this is a fragmented system. The number of physicians a typical primary care physician needs to coordinate care with is 229 physicians and 117 other practices; these numbers were published in the Annals of Internal Medicine. And if you just look at the one-third who have four or more chronic conditions—because those area the really expensive patients where care coordination is really important—the median number is still 86 physicians and 36 practices. So the net of all of this is that AMGA members are not simply attacking this with just informatics, they’re putting people in place whose job it is to coordinate care. It could be something as simple as planned visits, thinking through what’s going to happen at this next visit for this patient. When we talk about design of a care system is not only having the primary care and specialist physicians under the same roof, but being able to have those tools in place for people to use, and most importantly, having the people there. HIEs are a very valuable technology, but simply connecting EHRs—even if we solve the EHR adoption problem—is not going to automatically coordinate care.

How many organizations do you think are going to sign up for the Shared Savings Program in the next three years?

I think to some extent it will depend on how the commercial market evolves. Because some groups feel they can get their feet wet in population health management with maybe a little lower risk and less exposure if they approach it on a smaller scale with some of their commercial payers. The other thing that a lot of our groups are doing is working with employers in their regions. Those are people who tend to be interested in and be able to effect fairly broad interventions, including workplace health interventions and initiatives. I think that our groups are looking at all of those opportunities. There’s no question of long-term direction. The question is what is the best opportunity that each group has in its local market to learn how to do this using comparative data like that we’re providing and the shared learning. The model for how this team-based process works is still evolving. There are some very good best practices out there. For example, you can integrate with an employer and have a connection between the primary care that a population is receiving and a workplace health initiative. That’s a great opportunity.